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Ferry LH, Grissino LM, Runfola PS. Tobacco Dependence Curricula in US Undergraduate Medical Education. JAMA. 1999;282(9):825–829. doi:10.1001/jama.282.9.825
Author Affiliations: Department of Preventive Medicine, Loma Linda University Schools of Medicine and Public Health, Loma Linda, Calif. Dr Runfola is now with Concentra Managed Care Services, Phoenix, Ariz.
Context Tobacco use is the leading preventable cause of death in the United
States. And yet only 21% of practicing physicians claim they received adequate
training to help their patients stop smoking.
Objective To assess the content and extent of tobacco education and intervention
skills in US medical schools' curricula.
Design A survey with 13 multiple-response items on tobacco education. Survey
questions were based on the recommendations of the Agency for Health Care
Policy and Research and the National Cancer Institute Expert Panel. The Liaison
Committee on Medical Education included 4 of these items in a modified form
on the 1997 annual questionnaire.
Setting One hundred twenty-six US medical schools.
Participants Surveys were obtained from 122 associate deans for medical education
Main Outcome Measures Curriculum content in basic science and clinical science, elective or
required clinical experience, hours of instruction, and resource materials.
Results Inclusion of all 6 tobacco curricula content areas recommended by the
National Cancer Institute and the Agency for Health Care Policy and Research
was higher in basic science (63/115 [54.8%]) than in clinical science (5/115
[4.4%]). Most medical schools (83/120 [69.2%]) did not require clinical training
in smoking cessation techniques, while 23.5% (27/115) offered additional experience
as an elective course. Thirty-one percent (32/102) of schools averaged less
than 1 hour of instruction per year in smoking cessation techniques during
the 4 years of medical school. A minority of schools reported 3 or more hours
of clinical smoking cessation instruction in the third (14.7%) and fourth
Conclusions A majority of US medical school graduates are not adequately trained
to treat nicotine dependence. The major deficit is the lack of smoking cessation
instruction and evaluation in the clinical years. A model core tobacco curricula
that meets national recommendations should be developed and implemented in
all US medical schools.
Tobacco use, the leading cause of preventable death and disability in
the United States, accounts for nearly a half million premature deaths per
year.1 Although 70% of smokers visit a physician
each year, most are not advised or assisted in an attempt to quit.2 A 1991 survey showed that only 21% of practicing physicians
felt that their formal medical training prepared them to help patients stop
A randomized trial by Cummings and coworkers4
suggests that medical school is the optimal time for training in smoking cessation
techniques. An expert panel convened in 1992 by the National Cancer Institute
(NCI) recommended that effective smoking cessation and prevention interventions
become a mandatory component of undergraduate medical education in every US
medical school by 1995.5 The NCI panel also
recommended a systematic assessment of tobacco curricula in medical school
education. The only such published survey had been conducted by Horton6 in 1984 and was limited by a low response rate (51%).
A 1998 international curricula survey by the Tobacco Prevention Section of
the International Union Against Tuberculosis and Lung Disease had no specific
information on US medical schools, but evaluated North America as a whole
and had a 35% response rate.7,8
Our survey was designed to assess the content and extent of tobacco
curricula in US undergraduate medical education as suggested by the NCI panel.
For the purpose of this study, the phrase "tobacco curricula" includes epidemiology
of tobacco use, prevention, risk of tobacco-related diseases, and tobacco
dependence treatment. "Smoking cessation" includes behavior modification techniques,
pharmacotherapy, and counseling skills.
We designed the survey instrument to be a descriptive summary of tobacco
education in US medical school curricula. The questions reflected recommendations
for content areas of undergraduate education proposed by the Agency for Health
Care Policy and Research (AHCPR)9 and the NCI
Expert Panel.5 The 2-page survey consisted
of 13 multiple-response questions.
The first 2 sections of the survey addressed 6 basic science and 6 clinical
science content areas (Table 1).
These 12 topics were selected from AHCPR Clinical Practice Guideline No. 18
on Smoking Cessation9 and the NCI training
guide, How to Help Your Patients Stop Smoking.10 We modeled 1 question on a Liaison Committee for
Medical Education (LCME) questionnaire (1989-1990) that asked whether smoking
cessation was taught as a required course, as part of a required course, as
a separate elective course, as part of an elective course, or through other
educational experiences.5 Our survey asked
whether the 12 topics were covered as part of a required course, as a required
course dedicated to tobacco-related diseases, as an elective course, or not
offered. To investigate models of smoking cessation instruction, the following
options were listed: not required, required in (1) an artificial setting without
patients, (2) a clinical setting with patients, or (3) a clinical setting
with patients with evaluation of the student's performance. A third section
of the survey assessed the number of hours of instruction devoted to smoking
cessation in each year of medical school: none, less than 1 hour, 1 to 3 hours,
3 to 5 hours, or more than 5 hours.
Finally, resource materials used to develop the tobacco curriculum were
assessed. Options included the following: Guide to Clinical
Preventive Services,11 private educational
material, review of scientific literature, NCI's How to
Help Your Patients Stop Smoking,10 volunteer
agency material (such as American Lung Association, American Heart Association,
American Cancer Society literature), the Project ADEPT publication by Goldstein,12 AHCPR Clinical Practice Guideline No. 18,9 the Stop Smoking Kit from
the American Academy of Family Physicians,13
and the Clinician's Handbook of Preventive Services
manual from the US Department of Health and Human Services.14
The survey was pilot tested with leading tobacco control experts and
the associate deans of several medical schools. After incorporating their
suggestions, the revised survey was sent to the attention of the associate
dean for medical education at all 126 accredited US medical schools.15 Nonrespondents were sent a second survey and contacted
by telephone up to 3 times to encourage return of the completed survey.
In an effort to validate the findings from our voluntary survey, we
asked the LCME to include items from our survey in their annual (1996-1997)
questionnaire required of all US medical schools. The LCME questionnaire reformatted
4 items from our survey questions into 2 multiple-choice questions. Although
the LCME questions were not worded identically, the results have comparability
to validate similar items in our survey (Table 2).
Descriptive statistics summarized the survey responses of the US medical
schools. The McNemar test was used to compare the responses to the items included
in our survey and the tobacco items on the LCME questionnaire.
Multiple telephone calls and repeat mailings of our survey, beginning
with the pilot testing in March 1996, resulted in a 70% (88/126) return rate
by January 1997 and a final response rate of 96.8% (122/126) by July 1998.
Because the final 34 surveys were collected in the next academic year (1997-1998),
we compared the results of the early and late responders and found no significant
differences in the number of hours per year in the curriculum (2.4% maximum
difference) or content coverage between the 2 groups.
The LCME questionnaire for 1996-1997 yielded a 100% response rate due
to the obligatory nature of the questionnaire.
On the questions regarding basic and clinical science curricula, 94.3%
of the schools (115/122) responded. The nonrespondents to these specific items
were not included in this subanalysis; thus, 115 is used as the denominator.
Of the 6 basic science (first and second years) content areas (Table 1), a mean (SD) of 5.2 (1.2) topics
were covered. The inclusion of all 6 basic science topics was reported by
54.8% (63/115) of respondents.
For the 6 clinical science content areas (third and fourth years), a
mean (SD) of 2.6 (1.5) topics were reported covered. Only 4.4% of schools
(5/115) covered all 6 clinical science topics. Four percent (5/115) did not
report including any of the 6 clinical topics. Basic and clinical science
content areas are compared in Figure 1.
Almost all schools reporting tobacco curricula indicated basic science
content topics were "part of a required course" (98.3% [113/115]), and 23.5%
(27/115) of the schools offered additional experience as an "elective course."
Smoking cessation skills were more commonly reported as part of a required
course (67.2% [80/119]) than as an elective (14.3% [17/119]). Only 3 schools
(2.4%) had a required course devoted specifically to tobacco education: Boston
University, Bowman Gray University, and Loma Linda University. Twenty schools
(16.8% [20/119]) stated they did not require smoking cessation training, and
3 schools (2.5%) did not respond to the question.
We assessed whether the smoking cessation training included an artificial
or clinical setting and whether student performance was evaluated. The majority
of schools (69.2% [83/120])did not require any clinical training for smoking
cessation skills. Of the schools that required training in smoking cessation
techniques, 12.5% (15/120) provided an artificial setting without patients,
and 13.3% (16/120) provided a clinical setting with actual patients. Only
5.0% (6/120) of the schools required training in a clinical setting with an
evaluation of the student's performance.
One hundred two respondents (83.6% [102/122]) answered the section on
the number of hours of instruction on smoking cessation techniques in their
curriculum (Table 3). Eight schools
(6.6%) reported a total of less than 1 hour of instruction during all 4 years;
24 schools (19.7%) reported 1 to 3 hours of instruction, 10 schools (8.2%)
reported 3 to 5 hours of instruction, and 60 schools (49.2%) reported more
than 5 hours of instruction. Nearly one third of the respondent schools (31.4%
[32/102]) spent 3 hours or less on smoking cessation over the entire 4 years
of medical school.
An estimate of the limited smoking cessation curriculum can be made
by combining the number of schools that did not provide answers to this question
(20/122) with those that clearly indicated they had no hours of smoking cessation
instruction in each particular academic year. This provides a measure of low
commitment of academic medicine: first year, 64.7%; second year, 47.2%; third
year, 44.1%; and fourth year, 65.5%. The second (52.9% [54/102]) and third
(49.0% [50/102]) years consistently rate higher than the first (29.4% [30/102])
or fourth (17% [17/102]) years for including more than 1 hour of education
per year (combined categories of 1-3, 3-5, and >5 hours). Only 6 medical schools
(5.8%) provided more than 5 hours of instruction on tobacco intervention in
the clinical (third and fourth) years.
The resource most frequently cited for developing curricular content
was peer-reviewed scientific literature (47.5%). The next most commonly noted
resources were Guide to Clinical Preventive Services11 (31.1%), volunteer agencies (30.3%), and the NCI
training guide How to Help Your Patients Stop Smoking10 (27.0%). Although the AHCPR smoking cessation guideline9 had just been released in April 1996, 20.5% of the
schools reported using it. The 7-year-old office guidelines kit13
of the American Academy of Family Physicians was cited by 19.7% of the respondents,
and the Brown University Project ADEPT curriculum12
We compared the responses to those items that occurred on our survey
and on the 1996-1997 LCME questionnaire. The percentage of responses that
were the same on items from both instruments were as follows: clinical intervention,
78.9% to 84.5%; pharmacological agents, 84.5%; and clinical experiences with
actual patients, 54% to 82%. When we examined more closely where responses
differed on the 2 surveys, we found that for every item, significantly more
schools answered "yes" on the LCME questionnaire and "no" on our survey than
the other way around (P<.001 for each item; McNemar
A majority of US physicians and medical students are not adequately
trained to treat nicotine dependence, the most costly and deadly preventable
health care problem in the United States. The findings of our survey illustrate
the disparity between the effort (measured in time and curricula content)
spent teaching medical students about effective nicotine dependence treatment
and the enormity of tobacco's impact on health in the United States. To our
knowledge, there has been no other survey of tobacco education in US medical
schools in the past decade. Our survey is also the first to examine the content
areas, type of clinical setting for smoking cessation training, and the number
of hours devoted to tobacco curricula during each year of medical school.
The majority of medical schools have not incorporated the basic
smoking-cessation guidelines of the AHCPR (1996)9
and of the NCI Expert Panel (1992)5 into their
curricula. The recommendations of NCI's Expert Panel are even more imperative
in view of the failure to achieve the Healthy People 2000 goal to reduce the
national smoking prevalence to 15%.16 To achieve
the proposed Healthy People 2010 goal of 13%,17
undergraduate medical education must increase curricular attention to tobacco
use prevention and smoking cessation skills.
Attention to tobacco
content areas during the basic science years does not appear to be the major
problem. This is not surprising since many chronic diseases covered in a required
course, such as pathology, have their cause in tobacco use. However, the majority
of medical schools (69.2%) do not provide adequate training for clinical intervention
in the third- and fourth-year curricula. We acknowledge the possibility that
our data for the clinical years may reflect underreporting. Closer scrutiny
of the academic experience during the third- and fourth-year rotations may
reveal more smoking cessation skill instruction in informal settings than
reported by survey respondents. For example, on the 1989-1990 LCME questionnaire,
18% of schools provided training in "other educational experiences" rather
than in a required course.5
The variance in response to the LCME 1996-1997 questionnaire and ours
deserves comment. While a high degree of similar responses was found between
our survey and the 1996-1997 LCME questionnaire on instruction in clinical
intervention and pharmacology (78.9%-84.5%), less similarity was reported
for clinical training with patients (54%-82%). The possibility for bias exists
if schools responded more favorably to the mandatory LCME questionnaire. The
probability that a school would pick the same answer twice vs pick a "yes"
answer more often on the LCME items was not due to random error. It is possible
that the more favorable responses on the LCME survey reflect the approximate
6-month lag time between the 2 surveys, allowing for better identification
of the presence of tobacco dependence prevention and intervention curricula
when the later LCME questionnaire was completed. Still, the high response
rate to both surveys and the similarity of responses on most items gave us
confidence in the reliability of our results.
The 1989-1990 LCME
survey results indicated 57.5% of schools included smoking cessation as a
part of a required course; in our survey, the corresponding value was 67.2%.
This trend must be viewed in light of the absence of data on the effectiveness
of the curriculum to improve student knowledge and intervention skills, especially
in the clinical years.
Effective models to teach tobacco intervention
skills to medical students have been reported. Coultas et al18
found that training medical students with simulated patients resulted in an
increase in the effectiveness of smoking cessation interventions. The importance
of specific instruction and practice opportunity for development of clinical
smoking cessation skills was emphasized by Allen et al,19
who found that students without such experience were not able to translate
knowledge into a successful clinical encounter.
We propose the
development of updated core teaching materials that could be adapted by schools
to meet their particular needs. Key faculty at each school should be recruited
and trained to implement effective tobacco curriculum. Since nearly half of
medical schools (49.2%) reported more than 5 hours of instruction during 4
years, it seems reasonable to expect a minimum of 2 hours per year of instruction
for tobacco prevention and intervention skills at all US medical schools.
Inclusion of tobacco curricula questions on future LCME questionnaires
could bring the topic to the attention of the medical school administration
and document trends in curriculum development and focus. We also suggest greater
attention to tobacco prevention and intervention in future US Medical Licensing
Examinations to reflect the importance of tobacco's impact on America's health.
Until all medical schools place sufficient emphasis on the knowledge
base and intervention skills needed to prevent and treat chronic tobacco-related
diseases, it is unlikely we will see a decline in tobacco-related morbidity
and mortality. However, if medical schools provide universal training of medical
students in nicotine dependence intervention, tobacco users will have access
to the professional expertise they need to end the deadly cycle of nicotine
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